When physiological changes in a patient dictate a true need for oxygen, experts agree that the therapy should be administered, but many factors must be considered, including need, disease type, and potential alternative therapies.
By Phyllis Hanlon
Defined as care given to patients with chronic disease or progression of the disease process, palliative care focuses on creating comfort and enhancing quality of life. To accomplish this goal, clinicians administer a number of different therapies, one of which might be oxygen, in concert with the patient’s wishes.
Typically, patients with chronic pulmonary obstructive disease (COPD), pulmonary fibrosis, lung cancer and/or end-stage congestive heart failure (CHF) qualify for palliative care.
Cultural Obsession
Joseph Rotella, MD, MBA, HMDC, FAAHPM, chief medical officer at the American Academy of Hospice and Palliative Medicine (AAHPM), said, “Palliative care relieves pain and symptoms, addresses the whole person – mental, physical, emotional, social and practical. The intention of palliative care is neither prolonging life nor hastening death, but rather supporting the best quality of life possible in accordance with patient and family goals of care. The care is patient-centered and interdisciplinary and can be provided from any time during a serious illness. It can also be part of care when pursuing a cure.”
Oxygen is usually often one of the first interventions a patient and family request. “In our culture, oxygen has a strong meaning, but it may also be a strong placebo. In general many patients feel better [with oxygen], feel that it’s good for breathing,” said Rotella, but pointed out that it may not always be necessary. For example, television viewers may see an NFL football player who has just run down the field for a touchdown receiving oxygen on the sidelines. The public thinks it’s magic, according to Rotella. But the player is physically fit and does not necessarily need oxygen.
However, for the individual with a chronic respiratory condition specific signs may trigger consideration of oxygen therapy as a comfort measure. Rotella suggests the palliative care team take a cue from the patient, ask how he is feeling and whether he is experiencing air fatigue or limited functioning due to shortness of breath. Decreased oxygen levels in the blood could be causing dyspnea. “You might consider giving oxygen to see if it will help. But if oxygen doesn’t improve quality of life and meet the patient’s goals, then you don’t use it,” he said. “You don’t want to give oxygen just to raise the oxygen level when palliative care is the primary focus.”
Patient and Disease-Specific
Kenneth Miller, MEd, RRT-ACCS, NPS, AE-C, educational coordinator and Dean of Wellness, Respiratory Care Services at Lehigh Valley Health Network in Allentown, Pennsylvania, indicated a patient would typically manifest a physiological response when he needs oxygen. “Respiration is more than 30 times per minute. The patient might be breathing with his skeletal muscles and sternocleidomastoid muscles,” he said. “There could be paradoxical breathing. The patient’s chest concaves and there is increased work of breathing.”
In this case oxygen might be warranted, but Miller recommended high flow oxygen with a humidification system, much like mechanical ventilation, which adds warm, comfortable humidity. “It keeps the mucus thin so patients cough up secretions. The warmth is soothing,” he said.
Patients on cardiac monitors whose oxygen levels have dropped will demonstrate increased activity and patients on pulse oximeters will have lower oxygen saturation, Miller added, noting the importance of prompt attention to prevent serious adverse events from occurring. “We try to prevent a transitional period. When patients get to a really low oxygen level, it’s hard to get them back up. It’s like running a race. It’s hard to get your wind when you’ve already given your all. After a sustained period of 30 minutes of tachycardia or work of breathing, we would start high flow oxygen,” Miller said.
For patients dependent on continuous BiPAP, Miller suggested alternating oxygen therapy with occasional respite. “The patient needs to communicate, eat, have facial care. High flow oxygen gives the ability to do these things. The patient can’t be totally liberated, but we give time off the BiPAP,” he said.
Palliative care patients with chronic obstructive pulmonary disease (COPD) need treatment designed specifically for their particular disease process. “Some patients with COPD have high levels of carbon dioxide in their blood. When they breathe, they get rid of carbon dioxide and take in oxygen,” Rotella said. However, a certain group of patients builds up carbon dioxide due to lung disease. Administering too much oxygen to these patients could slow down breathing so it’s important to work with a pulmonologist. “Giving these patients anything more than two or three liters a minute could be risky and requires closer monitoring,” he added.
Interdisciplinary Care
Bronwyn Long, RN, DNP, palliative care and oncology nurse specialist who heads up the Palliative Care program at National Jewish Health in Denver, works together with the primary care team, which includes a pulmonologist for COPD patients and an oncologist for cancer patients. She noted that oxygen therapy for COPD patients requires a physician order and that those who do receive oxygen fare better in most cases. “We start low and go slow until we see benefits. Some COPD patients are stable on 14 liters. If the patient is doing well, we keep the oxygen saturation up,” Long said. “For interstitial lung disease and COPD you have to maintain oxygen levels. But for lung cancer patients who are not symptomatic, oxygen is not necessarily a part of treatment.”
Determining the most appropriate dosage should be done on a case-by-case basis, since the possibility for toxicity exists. “COPD patients can go up to 15 liters if they are very stable. Most go lower. There is more concern about too high a dosage, which could interfere with gas exchange,” Long said. “The doctor will look at the optimal flow rate.”
Lung cancer patients might initially struggle with the transition to oxygen. However, once they use it for a while, they can resume normal activities such as walking, riding a bike, hiking, according to Long. “They get a new lease on life when they wear supplemental oxygen. It gives them more quality of life again.”
In some cases, patients become comfortable with portable oxygen and accept it an integral part of day-to-day living. Long has witnessed some unusual, but impressive, patient responses to oxygen. “I’ve seen patients who are ‘bedazzled,’” she said. “Some people make the equipment a piece of jewelry.” She cited a woman who decorated her tank with stick-on jewels and glitter.
Home Care
When patients move from an inpatient setting to home care, delivering oxygen can impose a burden on the family, according to Rotella. He pointed out that in a clinic setting, hospital, emergency room or rehabilitation facility the entire oxygen delivery system is readily available. “[At home] you have to put in the delivery device. An oxygen concentrator is a good-sized appliance. It’s not portable, so where do you put it?” he said. Tubing can become a tripping hazard if it’s too long, but must be long enough to allow the patient room to move around freely.
Moreover, the oxygen concentrator relies on electricity so if a power outage occurs, the home must have a back-up system. Also, the cylinders are large and have to be stored in an upright position. “It’s worth it if it helps, but here are a lot of things to thing about. Additionally, an oxygen concentrator is loud, and some people are bothered by the noise created by oxygen-delivery systems. You also need to switch out the tanks, replace the filter, clean the bubbler and replace the tubing periodically,” Rotella added, noting that there is an increased risk of fire if the patient or family members smoke. “You can’t assume that oxygen is low risk and nontoxic. It’s not the first thing to reach for.”
The Oxygen Trial
Researchers from the Duke University School of Medicine and Duke Clinical Research Institute reported on The 2014 Oxygen Trial,1 which compared the use of oxygen versus room air, both delivered by nasal cannula, to relieve refractory dyspnea in patients with an adequate arterial carbon dioxide tension (PaCO2). In an outpatient setting at nine sites in Australia, the United States and the United Kingdom, 239 patients were randomized; 120 received oxygen and 119 received room air. Of those assigned oxygen, 112 (93%) completed all seven days of assessments; 99 (83%) on room air completed all assessments. The findings indicated that all subjects derived benefits within the first three days of the trial.
One factor that could impact the decision to administer oxygen therapy as part of palliative care is reimbursement. The study found “…lack of an established reimbursement mechanism for outpatient palliative care…can make it difficult to start a clinic even when it is clearly needed.”
The study authors noted that using oxygen therapy for dyspneic patients with advanced illness and adequate PaO2 added to the cost and increased patient discomfort without evidence of appreciable benefit. Their findings purport that room air via nasal cannula is just as effective, and less expensive, than oxygen. In fact, the authors cite evidence that merely placing a fan in front of a patient’s face would deliver similar benefits, is safe and cost effective. The latter intervention may be due to therapeutic effect or placebo, according to the authors.
Although oxygen therapy has become standard practice, The Oxygen Trial “…demonstrates the importance of challenging the status quo of often anecdotal evidence in palliative care, and shows how building the evidence base can change and improve practice in a meaningful way for patients and families, even while decreasing the cost of care.”
Long pointed out that the Centers for Medicare and Medicaid Services (CMS) must be kept apprised on an annual basis of the patient’s continuing need for oxygen; otherwise reimbursement for the therapy will be denied. However, patients with chronic respiratory conditions typically see their physician much more frequently than once a year so ongoing documentation from regular visits will back up the patient’s claim for oxygen. “Palliative is governed by the primary insurance. If you can’t demonstrate a need [for oxygen], you can’t get it,” she said.
Alternatives
While families and healthcare professionals often resort to oxygen as a first line treatment, other options could ameliorate shortness of breath. “There are a lot on non-medication treatments. Giving an opioid for pain has been shown to relieve the sensation of shortness of breath,” Rotella added. “A lot of people might think of oxygen before using morphine. But medical research shows that a low dose of an opioid can be effective in relieving symptoms and is safe for lung disease.”
Long lead a pilot study at National Jewish Health that looked at shortness of breath, depression and anxiety in COPD patients. Treatment options included liquid morphine 2 mg to 4 mg and lorazepam (Ativan), which is effective for nausea as well as panic and anxiety. She reported that all patients started with low dose morphine and never progressed to the lorazepam.
Intravenous or intramuscular morphine might alleviate pain and symptoms of shortness of breath, but the therapy has its disadvantages, according to Miller. “The patient can’t maintain his mental faculties. The patient wants to be as sharp as possible, understand what’s going on and interact with loved ones. Morphine blunts the cognitive function of the patient,” he said.
Rather than use an opioid, Miller suggested the use of high-flow oxygen to meet patient demands. “When you provide additional oxygen to increase levels, you reduce the work of breathing. So you decrease air hunger and allow the patient to be totally aware and retain mental faculties,” he said.
Also, aerosolized medications can open airways for patients with COPD, according to Miller. Bronchodilators, anticholinergics and anti-anxiety medications can also help. “Diuresing the patient with too much fluid can help. Also keeping the head of the bed elevated puts the patient in a good position and gives the diaphragm maximum ability to function,” he added.
As the name implies, palliative care involves treatment that offers comfort to a patient. When physiological changes in a patient dictate a true need for oxygen, experts agree that the therapy should be administered. But before beginning the treatment, other options including low-dose opioids and other medications might offer relief as effective as oxygen.
RT
Phyllis Hanlon is a contributing writer to RT. For further information, contact [email protected].
Reference
- LeBlanc TW, Abernethy AP. “Building the palliative care evidence base: Lessons from a randomized controlled trial of oxygen vs. room air for refractory dyspnea.” J Natl Compr Canc Netw. 2014 Jul;12(7):989-92.
I would like to thank RT Magazine for broaching the subject of oxygen utilization for palliative care. As in any discussion there are points that may be in question or subject to further clarification.
Point 1 is the myth of “Oxygen caused hypoventilation”. I say myth because there absolutely no scientific evidence to support the statement in the article – “a certain group of patients builds up carbon dioxide due to lung disease. Administering too much oxygen to these patients could slow down breathing so it’s important to work with a pulmonologist. Giving these patients anything more than two or three liters a minute could be risky and requires closer monitoring,” The concept of Hypoxic Drive has been espoused for so many years at every level of medicine that it has become accepted as fact. It is not fact. It is fiction. Any current review of the literature on the subject supports this fact – Oxygen inducted hypoventilation is a myth – never seen – never experienced. Withholding oxygen under a false concept on the other hand can be very discomforting if not possibly injurious.
Point 2 is that though compressed air may be just as effective as Oxygen in relieving breathlessness/dyspnea for some patients – if delivered by high pressure cylinder, it is just as expensive and requires the same effort and energy to setup on a home bound patient. Also, my experience is that about half of dyspneic patients find a fan comforting and the other half find it distressing. The only way to know which patient you have is to try it out and see.
Point 3 – Oxygen Toxicity is only a worry when a patient’s FiO2 is something north of .80. And, if this amount of oxygen is being required to maintain an adequate SaO2 (say 88% or more) in a palliative care environment – your patient will most likely expire well before OT will be a problem. That being said, it is useful from a cost and patient care aspect to titrate oxygen flows to meet patient need at the lowest possible level. In the homecare environment high flow oxygen (greater than 10 to 12 liters/minute) can be very expensive if not impossible to provide. We have done over 30 liters/minute using LOX, but the cost was exorbitant.
Thanks to Kevin for his remarks on this topic. I have heard that the “Haldane Effect” is a more likely cause for the simultaneous rise of PaO2 & PaCO2. I also agree with his comments on costs. Oxygen and compressed air are pretty cheap. The real expense is in the delivery to the homebound patient. While working for a home care business, I saw many oncology patients who developed breathlessness without hypoxemia. Trying to explain that Medicare would not help pay for the oxygen being requested was not an easy conversation to have.
Although the Haldane Effect can result in higher PaCO2 levels there is no Hypoventilation related to “depression of Hypoxic Drive” which is the myth that is getting reformulated here.
Factors other than hypoxemia can drive breathlessness. People really just want relief and if that can be provided by delivery of oxygen and/or providing a fan and/or the proper dosage of medications, most folks would be satisfied with positive results/outcomes.
why does oxygen make my heart palpitations go away?I have copd and lung cancer
In rare cases such as my husbands case, patients need more than 15 lpm, and in fact the higher dose prolongs life rather than shorting it.
Is it true that oxygen providers are restricted from delivering oxygen to your home if you need more than 15 LPM?
Hello, My daughter is Covid positive. She was admitted in the hospital for 6 days. Last night they sent her home. She is still suffering a lot and need a oxygen tank. I brought her a 5 liter but its not strong enough. She is also a asthmatic & have pneumonia. Do you have a bigger tank? If so, what size, price & how long do you think it will take to get too Brooklyn. Also, do you have a pymt plan?
Hi Teri, we’re sorry to hear your daughter is ill but glad to hear she is well enough to leave the hospital. We do not sell or distribute oxygen or other products. All supplemental oxygen requires a prescription so please speak to your primary care doctor about the right O2 product and the appropriate flow rate. They should connect you with a home medical equipment provider in your area.
It’s good to know that a lot of patients and families request oxygen first. It is essential for us to live. People might not know a lot about medical needs but they do know that oxygen is important.